Buteyko Method - Sleep Apnea by Patrick McKeown

Breathing re-education to
achieve nasal and normal
minute volume for sleep
PATRICK MCKEOWN MA
ButeykoClinic.com

Increased inflammation of upper and lower airways
Increased stickiness of upper airways
Reduced lung volume
Reduced nasal NO
Reduced ventilation/perfusion
Reduced messages to upper dilator muscles
Decreased ETCO2
Increased ventilatory response to CO2
Lighter sleep
Oral Breathing

More moist upper and lower airway
Reduced stickiness of upper airways
Improved lung volume
Nasal NO
Improved ventilation/perfusion
Increased messages to upper dilator muscles
More normal ETCO2
Reduced ventilatory response to CO2
Deeper sleep
Nasal Breathing

Reduced negative pressure in upper airways
Enhanced concentrations of nasal NO
Improved ventilation/perfusion
More normal ETCO2
Improved functioning of nasal airways- starling resistor model
Easier to maintain nasal breathing as less feeling of ‘suffocation’
Reduced ventilatory response to CO2
Normal Breathing Volume

Four key traits
Four key traits of upper airway anatomy and neuromuscular control
interact to varying degrees within individuals to cause OSA.
(1) Pharyngeal critical closing pressure
(2) Stability of ventilator chemoreflex feedback control (loop gain)
(3) The negative intraesophageal pressure that triggers arousal
(arousal threshold)
(4) The level of stimulus required to activate upper airway dilator
muscles (upper airway recruitment threshold).
AnnalsATS Volume 13 Number 1| January 2016

Pcrit
• Air pressure at which the passive airway collapses
• Fat deposition both around the pharynx and within upper airway
dilator muscles such as the genioglossus (tongue) decreases
airway lumen size and causes detrimental changes to upper airway
muscle function.

Pcrit
• Abdominal obesity compresses the abdomen and thoracic cavities,
reducing lung volume which reduces tracheal tension and thus
impairs pharyngeal mechanics.

Pcrit
• Therefore, fat deposition around the pharynx and torso
both increase airway collapsibility

Pcrit & Breathing Re-Education
Bernoulli Principle
• As fluid flows, a negative pressure develops at the periphery of the
flow and that as the flow velocity increases, so does the negative
pressure.
• (sucking through a paper straw)
Snoring and Obstructive Sleep Apnea. David N.F. Fairbanks and Samuel A. Mickelson

• 15 (±3) L/min (Twenty obese men with OSA and normal lung
function)
• 12.8 (±3.5 )11 obese men with overlap syndrome (OSA & COPD)
Radwan L, Maszczyk Z, Koziorowski A, Koziej M, Cieslicki J, Sliwinski P, Zielinski J.
Control of breathing in obstructive sleep apnea and in patients with the overlap
syndrome. Eur Respir J. 1995 Apr; 8(4): p.542-545.

• Minute ventilation mouth breathing (8.43)
• Nose breathing (9.37 )
Douglas NJ, White DP, Weil JV, Zwillich CW. Effect of breathing route on ventilation
and ventilatory drive. Respir Physiol. 1983 Feb;51(2):209-18.

Men
• Minute ventilation Wake: 10.6
• Minute ventilation sleep: 9.2
Women
• Minute ventilation Wake: 7.8
• Minute ventilation sleep: 7.2
Jordan AS, McEvoy RD, Edwards JK, et al. The influence of gender and upper airway
resistance on the ventilatory response to arousal in obstructive sleep apnoea in
humans. The Journal of Physiology. 2004;558(Pt 3):993-1004.

Minute Volume pre-trial: At three months follow up:
BBT 14 L BBT 9.6 L/min
Control Group 14.2 L/min Control Group 13.3 L/min
The relative reduction in beta2-agonist use in the BBT group was related to
the proportionate reduction in minute volume
Bowler SD, Green A, Mitchell CA, Buteyko breathing techniques in asthma: a blinded
randomised controlled trial. Med J of Australia 1998; 169: 575-578.

• The presence of a further upstream obstructive factor (nose) will
generate a suction force, that is, a negative intraluminal pressure
downstream (oropharynx), resulting in pharyngeal collapse in
predisposed individuals
De Sousa Michels Daniel et al. International Journal of Otolaryngology.
Volume 2014 (2014), Article ID 717419

• A closed jaw and proper dental occlusion stabilize the flow in the
upper airways .
• When nasal resistance exceeds a certain level, an air bypass occurs
and leads to mouth breathing, resulting in a decrease in the
retroglossal dimension, due to the subsequent retraction of the
tongue, narrowing of the pharyngeal lumen, and increased
oscillation and vibration of the soft palate and redundant tissue of
the pharynx .

10 normal men had full night recordings before and during nasal
obstruction.
During nasal obstruction, time spent in the deep sleep stages decreased
from 90 to 71 min, whereas significantly more time was spent in Stage
1 sleep.
Twofold increase in sleep arousals and awakening resulting from an
increased number of apneas (34 during control sleep versus 86 during
obstructed sleep).
Zwillich CW, Pickett C, Hanson FN, Weil JV Disturbed sleep and prolonged apnea during nasal
obstruction in normal men. J Pediatr (Rio J). 2011 Jul-Aug;87(4):357-63. Epub 2011 Jul 18.

• Apneas of 20 to 39s in duration became 2.5 times more frequent
during obstruction.
• De-saturation (SaO2 less than 90%) occurred 27 times during
control sleep compared with 255 times during obstructed sleep.
Disturbed sleep and prolonged apnea during nasal obstruction in normal men. Am
Rev Respir Dis. 1981 Aug;124(2):158-60.

Loop Gain
• During sleep, ventilatory control is dominated by the level of CO2
and O2 in the blood. Arterial CO2 has the greater influence, with
increasing CO2 stimulating an increase in ventilatory drive.
Annals ATS Volume 13 Number 1| January 2016

Loop Gain
• Ventilatory drive determines not only the level of activity of the
thoracic pump muscles but also the upper airway dilator muscles.
• Consequently, the upper airway is susceptible to collapse when
CO2, and therefore neural drive to the upper airway muscles, is
low.

Loop Gain
• When the central respiratory output waxes and wanes, the activity
of the upper airway dilator muscles varies accordingly so that
periods of low central respiratory drive are associated with low
upper airway dilator muscle activity, high airway resistance, and a
predisposition to airway collapse.
• Thus, respiratory control instability (also known as high loop gain)
is probably a causative factor of obstructive sleep apnoea in some
patients.
Lancet. 2014 February 22; 383(9918): 736–747.

Loop Gain
• After arousal, most people hyperventilate briefly and if large
enough, CO2 concentration in blood can fall below the chemical
apnoea threshold, resulting in a central apnoea.
Lancet. 2014 February 22; 383(9918): 736–747.

• After a switch to oral breathing during sleep, there is greater
CO2 elimination during expiration, caused by an increase in
respiratory stimulus. The increase in central apneas suggests that
the nose plays an important role in the regulation of respiration
and not only in the maintenance of airway patency.
Loop Gain

Loop Gain
• Ventilatory responses were greater with mouth than nose
breathing both for hypercapnia (mouth 2.29, nose 1.58 L/min/mm
Hg CO2; ) and for hypoxia (mouth 1.08 nose 0.91 +/- 0.21 L/min/%
SaO2;).
• (lowers loop gain. More stable)
Douglas NJ, White DP, Weil JV, Zwillich CW. Effect of breathing route on ventilation
and ventilatory drive. Respir Physiol. 1983 Feb;51(2):209-18.

Loop Gain
• Higher loop gain defines less-stable control, as a
disproportionately large ventilatory response will result in a
greater degree of hypocapnia and subsequent reduction in
ventilatory drive.

Loop Gain
• Thus, high loop gain contributes to perpetuating apneas.
Supporting this concept is evidence that patients with OSA have
higher loop gain than patients without OSA and that loop gain
predicts AHI.

• Mouth breathing increase the ‘dryness’ of the upper airway
mucosal surface.
• Increased wall ‘stickiness’ may then make the upper airway more
difficult to reopen after closure.
Manisha Verma, Margaret Seto-Poon, John R Wheatley, Terence C Amis, Jason P
Kirkness. Influence of breathing route on upper airway lining liquid surface tension in
humans. J Physiol. 2006 Aug 1; 574(Pt 3): 859–866.
Loop Gain

• Increased lung volume also probably stabilises the respiratory
control system by increasing the stores of O2 and CO2 and thus,
buffering the blood gases from changes in ventilation.
Lancet. 2014 Feb 22; 383(9918): 736–747
Loop Gain

Arousal Threshold
• Another potentially important factor is the propensity to arouse
from sleep (the arousal threshold).
Lancet. 2014 February 22; 383(9918)
• Increasing negative intraesophageal pressure during airway
obstruction triggers arousal, and the change from sleep to wake
increases basal chemoreflex drive and sensitivity.

Arousal Threshold
• Individuals with low arousal thresholds might arouse before the
dilator muscles are able to reopen the airway.
• Delay of arousal with sedatives might help to treat the condition if
the upper airway muscles are sufficiently responsive to respiratory
stimuli to stabilise the airway before arousal.
Amy S. Jordan, PhD, David G. McSharry, MB, and Prof. Atul Malhotra, Adult
obstructive sleep apnoea Lancet. 2014 Feb 22; 383(9918): 736–747

Arousal Threshold
• Obstructive events terminated by arousal result in a greater
degree of hyperventilation and consequent hypocapnia and
reduction in ventilatory drive, including drive to upper airway
muscles.

Upper Airway Recruitment Threshold
• If the upper airway muscle responsiveness is sufficiently
poor, then arousal is necessary to initiate airway opening .

Arousal Threshold
• Thus, arousals may perpetuate successive obstructions.
• A high arousal threshold (aroused by more negative pressures)
appears to develop in many patients with OSA as an adaptive
mechanism, as a greater magnitude of both negative pressure
stimuli and chemostimulation can accumulate to recruit upper
airway dilator muscles to terminate the event before arousal.

Upper Airway
Recruitment
Threshold

• The magnitude of stimuli (both negative pressure stimuli and
chemostimulation) required to recruit upper airway dilator
muscles adequately to overcome negative intrapharyngeal closing
pressures is called the upper airway recruitment threshold.

• Poor upper airway muscle responsiveness increases the duration
of obstructive events, as greater stimuli are required to activate
the muscles to terminate the obstruction.

• Increased chemoreflex drive due to both prolonged obstruction
and arousal increases the ventilatory response after airway
opening. Thus, poor upper airway recruitment interacts with
arousal threshold and loop gain to contribute to repetitive apnea.

• NO appears to play a role in maintaining the patency of the upper
airways, as a transmitter between the nose, pharyngeal muscles,
and lungs. NO is produced in significant quantities in the nose and
in the paranasal sinuses .

• Nitric oxide and carbon dioxide may also act as aerocrine
messengers. Physiological, epidemiological, and clinical evidence
support a “unified airway” model.
James Bartley, Conroy Wong. Nasal Physiology and Pathophysiology of Nasal Disorders
pp 559-566. Date: 27 June 2013

• NO also plays a role in the maintenance of muscle tone, regulation
of neuromuscular pathways in the pharyngeal muscles,
spontaneous respiration, and sleep regulation. In general, the role
of NO in the regulation of nasal OSAS, although probably
significant, is still not completely understood.

• As the total amount of inspired NO varies according to the nasal
flow, it appears logical that a decrease in nasal breathing would
result in reduction of NO delivery to the lungs.
• Ventilation-perfusion ratio.

• Prevalence between asthma and OSA ranges from 38% up to as
high as 70%.
• Based on the current concepts of bidirectional relationship
of OSA and asthma, it is sensible to assume that treating one
disorder will result in the other's better control and vice versa.
Abdul Razak MR, Chirakalwasan N .Obstructive sleep apnea and asthma. Asian Pac J
Allergy Immunol. 2016 Dec;34(4):265-271.

• The lower and upper airways are mechanically linked, so that with
increased lung volumes, resulting in stiffening and dilation of the
pharyngeal airway.
Amy S. Jordan, PhD, David G. McSharry, MB, and Prof. Atul Malhotra, MD
Adult obstructive sleep apnoea Lancet. 2014 Feb 22; 383(9918): 736–747.

Research to determine
• Controlled, randomized, single-blind study. Breathing reeducation
on asthmatic mouth breathing children. 35 children with mild or
moderate asthma in the age group between 7 and 12 years.
• Karla M.P.P. Mendonca , Thalita M.F. Macedo , Diana A. Freitas , Ada C.J.S. Silva , Cleia T.
Amaral , Thayla A. Santino , Patrick McKeown . American Journal of Respiratory and Critical Care
Medicine 2017;195:A2204 . Buteyko Method for Children with Asthma and Mouth Breathing: A
Randomized Controlled Trial

• Breathing re-education group significantly improved the scores on
sleep disturbances, wakefulness disorders, sleep wake transition
disorders (DTSV), the number of days off school, total sleep
disturbance scores, forced vital capacity (FVC), peak Expiratory
flow and forced expiratory flow between 25% and 75% of FVC
(FEF25-75%).
• Karla M.P.P. Mendonca , Thalita M.F. Macedo , Diana A. Freitas , Ada C.J.S. Silva , Cleia T.
Amaral , Thayla A. Santino , Patrick McKeown . American Journal of Respiratory and Critical Care
Medicine 2017;195:A2204 . Buteyko Method for Children with Asthma and Mouth Breathing: A
Randomized Controlled Trial

26 volunteers with a diagnosis of asthma
and chronic rhinitis, ranging in age from
23 – 60 years were recruited from the
general population.
Adelola O.A., Oosthuiven J.C., Fenton J.E. Role of Buteyko
breathing technique in asthmatics with nasal symptoms.
Clinical Otolaryngology.2013, April;38(2):190-191

• Relationship between minute volume and OSA
• Breathing pattern during wakefulness and sleep
• Normalisation of breathing pattern during wakefulness carries into
sleep
• Can breathing re-education prove to be an effective adjunctive
measure for patients with CPAP or treated with surgery?

QUESTIONS:
E: patrick@buteykoclinic.com

Buteyko Method - Sleep Apnea by Patrick McKeown

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